title: Prevention of vascular access hand ischemia using the axillary artery as inflow.
abstract: BACKGROUND
  Avoiding dialysis access-associated ischemic steal syndrome (DASS) in patients with upper extremity peripheral vascular occlusive disease while creating a functional hemodialysis vascular access may be challenging. We constructed an autogenous access with primary proximalization of the arterial inflow to prevent hand ischemia in patients at high risk for this complication.
  
  
  METHODS
  Patients requiring hemodialysis access with physical findings suggesting a high risk of access-related hand ischemia (absent radial, ulnar, and brachial palpable pulses associated with small calcified vessels by ultrasound examination) underwent a primary arteriovenous fistula transposition procedure utilizing the axillary artery for inflow. The arteriovenous fistula was either a reversed flow basilic vein transposition supplemented by valvulotomy (n = 22); a translocated reversed basilic vein (n = 4); a cephalic vein harvested into the forearm and placed in a loop configuration for axillary artery inflow (n = 3); or a translocated reversed saphenous vein (n = 1).
  
  
  RESULTS
  Thirty patients with a mean age of 60 years (range, 31-83 years) underwent successful primary axillary artery inflow procedures during a 3-year period. Of these, 23 (77%) were female and 25 (83%) were diabetic. Twenty-one (70%) had previous vascular access procedures and 10 (33%) were obese. No patient developed postoperative ischemia. Three individuals died 2, 14, and 19 months following surgery, none related to vascular access. Three accesses failed after 1, 5, and 7 months and could not be salvaged. Life-table primary, primary assisted, and cumulative patency rates were 57%, 78%, and 87% respectively at 1 year with a mean follow-up of 7 months (range, 1-25 months). Cephalic vein outflow was associated with fewer access failures, fewer interventions postoperatively, and lower rates of arm swelling (P < .01).
  
  
  CONCLUSIONS
  Creating a basilic vein transposition for vascular access utilizing axillary artery inflow is a good option for patients with severe peripheral vascular disease. It offers a high patency rate and the prevention of DASS. Retrograde basilic vein outflow through the median cubital and cephalic vein is associated with the best outcome and is the recommended configuration.
authors.affiliation: Department of Surgery, University of Oklahoma College of Medicine-Tulsa, Tulsa, Okla. Electronic address: William-Jennings@ouhsc.edu.
authors.forename: William
authors.initials: W
authors.lastname: Jennings
authors.forename: Robert
authors.initials: R
authors.lastname: Brown
authors.forename: John
authors.initials: J
authors.lastname: Blebea
authors.forename: Kevin
authors.initials: K
authors.lastname: Taubman
authors.forename: Ryan
authors.initials: R
authors.lastname: Messiner
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects / Q000379:methods*; D001366:Axillary Artery / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006225:Hand / Q000098:blood supply*; D006801:Humans; D007511:Ischemia / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency; D014680:Veins / Q000601:surgery